Malaria Control : Technical Updates

1. Malaria Control : Technical Updates IFRC Global Fund Round 11 workshop: Supporting National Society Engagement in Global Fund Round 11 Geneva, Switzerland 3-7 October, 2011 Dr. Peter OLUMESE, MB;BS, FMCPaed Medical Officer Global Malaria Programme WHO, Geneva, Switzerland.

2. Malaria Control Technical Strategies …..evidence-based actions • Early diagnosis and prompt treatment with effective medicines • Insecticide-treated nets (ITNs), Indoor Residual Spraying (IRS), and other vector-control methods • Intermittent preventive treatment in pregnancy (IPTp) • Intermittent preventive treatment in Infants (IPTi) • Emergency and epidemic preparedness and response

3. Key antimalarial interventions & strategies Strengthening health systems in endemic countries Prevention • Insecticide-treated bednets (ITNs) / Long-lasting ITNs (LLINs) • Indoor Residual Spraying In areas of moderate to high and stable transmission • IPT in pregnancy (IPTp) • IPT in infancy (IPTi) Diagnosis & Treatment • Parasite based diagnosis • Microscopy • Rapid Diagnostic Tests • Artemisinin-based combination therapies (ACTs) • Case management: • Health facilities • Community Case Management (aka HMM) • Private sector Surveillance, M & E • Routine HMIS • Malaria surveillance and response systems • Household surveys

4. Diagnosis and Treatment with Effective Medicines (Malaria Case Management)

5. Objectives of case management Uncomplicated malaria Cure of infection (eradication from the body the infection that caused the illness requiring treatment), thus preventing progression to severe disease reduce transmission (reduce infectious reservoir) prevent the emergence and spread of antimalarial drug resistance Severe Malaria the primary objective is to prevent death preventing neurological deficits

6. Components of Malaria Case Management Malaria diagnosis (clinical and parasitological confirmation) WHO recommends confirmation of malaria through parasite-based diagnosis in all patients prior to instituting treatment Prompt and effective treatment within 24 hours of the onset of symptoms: Artemisinin-based combination therapies (ACTs) in uncomplicated falciparum malaria - including in infants, people living with HIV/AIDS, community case management of malaria and pregnant women Parenteral artemisinin derivative plus ACTs in severe malaria Support intervention for effective case management BCC & Health education Disease surveillance and M&E Monitoring resistance of antimalarial medicines (therapeutic efficacy monitoring) Pharmacovigilance

7. Malaria Diagnosis Prompt parasitological confirmation by microscopy or alternatively by RDTs is recommended in all patients suspected of malaria before treatment is started. Treatment solely on the basis of clinical suspicion should only be considered when a parasitological diagnosis is not accessible Malaria endemic countries should as a matter of priority examine and address all financial and logistic (managerial, administrative) requirement needed to establish universal parasitological diagnosis systems During the transition to achieving universal diagnosis, treatment solely on the basis of clinical suspicion should not be withheld from these clinically suspected cases

8. Confirmatory diagnosis • Parasitological diagnosis has the following advantages: • Improved disease case management • improved patient care in parasite-positive patients; • identification of parasite-negative patients in whom another diagnosis must be sought; • Confirmation of treatment failures • prevention of unnecessary use of antimalarials, reducing frequency of adverse effects, especially in those who do not need the medicines, and drug pressure selecting for resistant parasites; • improved malaria case detection and reporting

9. Effective parasitological diagnosis requires … • Robust supply chain system (commodities) • Quality assurance / control programme • Competency-based training and accreditation (re-training) • Technical supervision • Adherence to test results – providers and patients • Health education and information at all levels

10. Treatment of Uncomplicated Falciparum Malaria • Artemisinin-based combination therapies (ACTs) are the recommended treatments for uncomplicated falciparum malaria. • The following ACTs options are recommended: • Artemether + lumefantrine; artesunate + amodiaquine; artesunate + mefloquine; artesunate + sulfadoxine-pyrimethamine; and dihydroartemisinin + piperaquine . • Second-line antimalarial treatment: • Alternative effective ACT; • Artesunate plus tetracycline or doxycycline or clindamycin. • Quinine plus tetracycline or doxycycline or clindamycin. • Anti-gamecytocidal treatment • Single dose of primaquine (0.75mg/kg) used for its antigamecytocidal action in the treatment of falciparum malaria, (especially in the pre-elimination and elimination programmes).

11. Treatment of severe malaria • Parenteral artesunate (i.v or i.m) is the medicine of choice in all age groups and in all transmission settings • Artemether and Quinine are acceptable alternatives if artesunate is not available. • Give parenteral antimalarials for a minimum of 24hrs once started (irrespective of the patient's ability to tolerate oral medication earlier), and, thereafter, complete treatment by giving a complete course of: • an ACT • artesunate + clindamycin or doxycycline • quinine + clindamycin or doxycycline. • NOTE: • GF Grant request, should include where indicated, funding for update and implementation of revised severe malaria guidelines • Printing of guidelines, job-aids, etc. • Training of health workers • Establishing an effective supply chain for artesunate

12. Pre-referral treatment Single dose treatment • Artesunate or artemisinin by rectal administration • Artesunate or artemether (i.m) • Quinine (i.m) • Follow-up treatment • Refer the patient as soon as feasible to a centre where full management is available • Where referral is not possible • rectal treatment should be continued until the patient can tolerate oral medication, then • administer a complete course of an effective ACT

13. Community Case Management of Malaria (CCMm) WHO encourages that CCM of malaria be delivered as part of integrated CCM (iCCM), which includes the treatment of pneumonia and diarrheal diseases.

14. IMCI: Updated Algorithm to include malaria diagnosis

15. What is in the Package for CMM malaria?... • Trained community providers (CHWs, Medicine Sellers or Retailers) should be provided with: • ACTs for treatment of uncomplicated malaria. • Rectal artemisinin suppositories for pre-referral treatment of severe malaria. • Rapid diagnostic tests • Information, Education and Communication materials. • simple patient registers and reporting forms.

16. Antimalarial drug resistance • A major public health problem with potential to hinder the control and elimination of malaria • Artemesinin resistance reported on the Cambodia-Thailand border in 2008 • WHO, together with RBM partners have developed the Global Plan for Artemisinin Resistance Contaminent (GPARC).

18. Applying recommendations at country level • each endemic country is expected to evaluate its level of risk and then to apply the GPARC recommendations accordingly in designing a containment or prevention programme. • 3 levels or tiers of countries are defined: • Tier 1 • areas for which there is credible evidence of artemisinin resistance • Tier II • areas with significant inflows of mobile and migrant populations from tier I areas or shared borders with tier I areas. • Tier III • P. falciparum areas which have no evidence of artemisinin resistance and limited contact with tier I areas

20. Tier III • Main goal is to prevent the emergence of artemisinin resistance. • implementation and scaling-up of effective control measures should be continued, including • increasing access to parasitological diagnosis for all patients suspected of having malaria, • improving access to quality-assured ACTs for confirmed cases and • increasing coverage with vector control to limit malaria transmission. • In addition, tier III areas should undertake two other components of good control: • Monitor the therapeutic efficacy of first- and second-line treatments every 24 months, as recommended by WHO. • In areas in which there is extensive use of oral artemisinin-based monotherapies or poor-quality drugs, introduce or enforce actions to eliminate their use.

21. Monitoring Antimalarial Drug Resistance Global database on therapeutic efficacy of antimalarials:www.who.int/malaria/resistance.htm • Establishment of 4 to 8 sites in each country • Therapeutic efficacy study of 1st and 2nd line • antimalarial medicines should be conducted at • least once every 24 months in all sites • All studies must be accompanied by molecular • assessment (e.g. PCR) to assist in distinguishing • recrudescence from re-infections • All studies must be conducted in accordance with • the WHO testing protocol.

22. Monotherapy…. • Current packaging of ACTs • Fixed dose formulation available only for 2 of the currently recommended options • Blisters treatment course packaging also provides a challenge of ensuring that both components of the ACT is used by the patients, and not just using 3 days artesunate • Use of ACTs whose the partner medicines is not efficacious = to artemisinin monotherapy used for only 3 days….

23. Malaria Vector Control Coreinterventions Mosquito nets - Long-Lasting Insecticidal Nets (LLINs) Indoor Residual Spraying (IRS) In selected countries and situations, the above can be complemented based on local needs by Larval control Environmental management

24. Vector Control WHO recommends Universal Coverage of the population at risk of malaria with effective vector control measures LLINs Provided in sufficient numbers to cover everyone exposed to transmission in targeted communities Combination of campaign (catch-up) and routine (keep-up) systems of distribution will be needed to sustain this coverage. WHOPES- approved LLINs with insecticide lasting for 3 years. However the physical lifespan of the nets play a significant role in determining replacements. IRS Highly effective intervention providing protection to communities through a rapid mass effect on vector populations. Quality of spraying critical for effectiveness At least 80% of premises in targeted communities properly sprayed Cycle of spraying depends on the insecticide used, the type of surface sprayed, and the seasonality of transmission.

25. Insecticide resistance management All malaria vector control programmes must have an insecticide resistance prevention and management strategy Some key components include to alternate between insecticide classes (different mode of action) in rotation system for IRS a pyrethroid may be used as one element of the rotation, except where there is high LLIN coverage resistance monitoring must be conducted at least once a year from several locations that are targeted for vector control activities using the conventional bioassay and molecular genotyping methods. where IRS is undertaken, data on insecticide resistance must be collected in the target area, before and after the spray operations.

26. Malaria in Pregnancy Case management of malaria and anaemia Insecticides treated nets (ITNs) Intermittent preventive treatment (IPTp)

27. Intermittent Preventive Treatment • …."current evidence to date suggests that the benefits of IPTp (SP) outweighs the risks in countries in cub-Saharan Africa with stable transmission" – (WHO July '07) • at least 2 doses of SP, given at the 1st and 2nd regularly scheduled ANC visit after "quickening". • Systems to deliver IPT through the ANC / reproductive health programs • Training • Logistics, etc… to be costed for!

28. Intermittent preventive treatment in infancy (IPTi) .... the administration of a full course of an effective anti-malarial treatment at specified time points to infants at risk of malaria, regardless of whether or not they are infected with malaria, with the objective of reducing the infant malaria burden. SP-IPTi delivered through EPI is recommended as an additional malaria control intervention in countries in Africa, south of the Sahara where malaria transmission is moderate to high

29. IPTi – Implementation issues • Countries adopting this policy should include their Global fund proposal funding for • Policy adoption and implementation • Development of national implementation guidelines • Training of health workers • Development of advocacy and BCC materials • Procurement and distribution of antimalarial medicine (SP) • Strengthening of M&E and surviellance systems to include IPTi • These should be planned and executed in collaboration with EPI programme

30. Epidemics and complex emergencies

31. Monitoring and Evaluation • Comprehensive annual reference on the status of global malaria control & elimination • Principal data source is national malaria programmes in 106 endemic countries with support from: WHO Regional offices, ACT Watch, CDC, Global Fund, IHME, IRI, JHU, RBM, Tulane University • Summarizes key malaria targets & goals • Documents trends in financing, intervention coverage and impact (malaria burden) • Provides country-by-country summaries • Updates malaria burden estimates for entire decade: 2000-2009 World Malaria Report 2010

32. Malaria surveillance Surveillance data should be principal source of information in endemic countries at all levels to: monitor burden and trends of malaria evaluate impact of intervention respond to increases in transmission Control and ultimately elimination of malaria requires timely and complete malaria surveillance at all levels of the health care system

33. Malaria Elimination

34. Definitions Malaria control: reducing disease burden to a level where it is no longer a public health problem Eradication: permanent reduction to zero of the worldwide incidence of infection caused by a specific agent Elimination: reduction to zero of the incidence of infection caused by a specific agent in a defined geographical area interruption of local mosquito-borne malaria transmission Malaria-free area: area where there is no ongoing local mosquito-borne malaria transmission, and the risk of acquiring malaria is limited to introduced cases only

35. Control to elimination continuum

36. Effective malaria control: Comprehensive package! WHO Policy brief and A compilation of WHO reference documents - http://www.who.int/malaria/publications/atoz/malaria_gf_proposal_dev_who_policy_brief/en/index.html

37. Thank you Keep our eye on the prize: a world free of malaria